| NPI | 1417964321 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: OR D6668) |
| Additional Taxonomies | 1223S0112X Dentist, Oral and Maxillofacial Surgery (Licence: ID D-3163-OS) |
| Enumeration Date | 2006-08-02 |
| Last Update Date | 2015-06-17 |